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II
3. Elimination
a. Bowel and urinary Pt urinates 5x/day and Pt urinates 250ml with the Pt urinates 1600ml with the Pt urinates 1000ml with the Pt urinates 1400ml with the
excretion patterns the color is white and color of yellow and not color of yellow and not color of yellow and not color of yellow and not
defecate yet. defecate yet. defecate yet. defecate yet.
yellow.
b. Perceived regularity
or irregularity of Irregular Irregular Irregular Irregular
elimination Pt. usually defecate
once a day.
c. Use of laxatives or
routines No use of laxatives. No use of laxatives No use of laxatives No use of laxatives No use of laxatives
d. Changes in time,
modes. Quality or
quantity of
excretions
e. Use of devices for No device used. No device used. No device used. No device used. No device used.
control
c. Factors interfering
with the desired
pattern
5. Sleep – Rest
a. Patterns of sleep
and rest-/relaxation Pt. usually sleeps 8pm and
in a 24-h period wakes up at 4am.
Pt’s SO feels she had an
b. Perception of quality Pt feels she had adequate adequate rest and sleep No significant changes No significant changes No significant changes
and quantity of rest and sleep. due to her illness.
sleep and rest
None
c. Use of sleep aids None
and routines
6. Cognitive – Perceptual
a. Adequacy of vision, Pt. no report of changes in Pt. R eye is not
hearing, taste, vision, hearing, touch and reactive to light.
touch, smell smell. There is a changes No significant changes No significant changes No significant changes
in food preferences.
b. Pain perception and
management
c. Language,
judgment, memory,
decisions
8. Role-Relationships
a. Perception of major Pt role as a mother to her Pt role as a mother and wife
roles, relationships, four children and a good is good as verbalized by her
and responsibilities wife to her husband. husband.
in current life No significant changes
situation Pt is satisfied to her roles. No significant changes No significant changes
Pt is satisfied to her roles.
b. Satisfaction with or
disturbances in roles
and
relationships
Compensates by
d. Perceived ability to practicing a healthy
control and manage lifestyle (exercise, eating
situations nutritious foods, adequate
rest)
11. Value-Belief
a. Values, goals, or Pt believes in GOD as the Pt believes in God as the
beliefs (including divine creator and divine creator and healer of
spirituality) that supreme provider. mankind.
guide choices or No significant changes No significant changes No significant changes
decisions
Pt perceives conflicts ill Perceives conflict will
b. Perceived conflicts resolves by working hard resolve by hard work and
in values, beliefs, or and asking God’s asking God’s assistance
expectations that assistance and blessings and blessings through
are health related through prayer. prayer.